Thursday, July 7, 2011

Through the Cracks: Suresh Nair

On a Saturday afternoon in November 2009, a sergeant at Kings Cross Police Station received a call from Helen Lonergan, the administrative head of Nepean Private Hospital. She was trying to discover the whereabouts of Suresh Nair, a neurosurgeon responsible for several in-patients who, three days after their operations, had still not been reviewed. Each had undergone a major procedure upon their spine; one required monitoring in intensive care.

Lonergan, who had appointed Nair three years earlier, had only a vague idea that he might suffer from a mental illness. Nair was also employed by the public hospital adjacent to the Nepean; the Medical Board had stipulated Nair must work under supervision and could operate just one day per week in the private sector. After his protracted absence, hospital staff had been trying to reach him by phone for days. Lonergan was worried about a possible decline in his condition, maybe even a suicide attempt.

When the local sergeant pulled up Nair’s name on the police database, he discovered the doctor was already under investigation and ordered an immediate search. Police arrived at Nair’s luxury pad in Elizabeth Bay to find it vacant. But they did discover the dead body of a beautiful young woman, Brazilian student Suellen Domingues Zaupa, on the floor.

The following Monday, not having heard anything further from police, Lonergan was preparing to shift Nair’s patients to other surgeons. But Nair had already been to work that morning and reviewed the patients who had been waiting to see him. Staff described him as calm and composed. He had apologised for his disappearance and lack of contact, citing a family crisis.

Later that day, police called the hospital and urged its administrators to suspend Nair from operating immediately, without revealing why. Lonergan waited anxiously after making special requests for confidential information to help determine whether the hospital would allow Nair to operate on a full list of patients the following day. The information arrived from police headquarters just in time.

Nair was found to have engaged the services of several high-end escorts over a long period of time. At his insistence he shared cocaine with them, sometimes inserting thumbnail-sized parcels of the drug into their vaginas and rectums, which increases the rate of absorption.

Nair’s activities may have resulted in Zaupa’s death. After she lost consciousness, Nair moved his Dionysian party of cocaine and prostitutes to a penthouse suite in a city hotel. Another woman, Victoria McIntyre, had been found dead in his apartment nine months earlier. He wasn’t yet charged for this earlier event, and neither the Medical Board nor Nair’s employers had been informed about it.

Nair was initially charged with murder over Zaupa’s death but the charge was downgraded and he ultimately pleaded guilty to manslaughter. He also pleaded guilty to the charge of supplying drugs to McIntyre. When released on bail in the middle of last year he was immediately discovered, thanks to police surveillance, to be hiring prostitutes and using cocaine. Further requests for bail were promptly refused. He was charged in January and will be handed a sentence at the end of this month.

When I meet Nair briefly at Sydney’s Silverwater jail for inmates on remand awaiting sentencing, it strikes me that his white prison uniform – a robe hanging over the knees, tied around the neck with a ribbon – could double as a lab coat or surgical gown. Of medium build, Nair’s neatly trimmed hair exposes shades of grey on the side of his scalp.

He refuses to talk about his charges, instead inveighing against the harshness of the jail experience, particularly for a white-collar professional in a group he describes as being full of thugs, thieves and drug dealers. He speaks about the poor fit of someone from an Indian background in an environment clearly delineated by ethnicity into Lebanese, Pacific Islander and Caucasian tribes. He says he was relieved when a group of alleged people smugglers, up for charges of illegal fishing, were transferred from Darwin to the facility; he tells me his Indonesian language skills endeared him to the group.

His key concerns from his public downfall, he says, are the hurt the media reports have caused his family and the prospect his reputation as a competent surgeon will be irreparably damaged.

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Nair was born in Malaysia to Indian parents who migrated to Australia when Suresh was ten. They returned home a decade later, while Suresh pursued a medical degree at the University of Sydney. Several of his fellow students remembered him as a very polite student who always greeted them when he passed. The collators of his graduation class yearbook seemed to have considerable foresight when they suggested Nair was among the most likely to end up in prison, commenting: “Give him a good Penthouse and he’s happy.” He developed the nickname “sex rash” among his peers for his dirty sense of humour and penchant for pornography. While never an outstanding student, he was able to pass the appropriate hurdles in medical school before completing residency and embarking on surgical training.

Medical training is a gruelling experience, the easiest part of which is arguably the undergraduate university stage, lasting five or six years. The postgraduate component is arduous, involving very long hours, life and death decision-making, and examinations of heartbreaking intensity – with high failure rates. Neurosurgery is a specialism with particular glamour and prestige. It combines skills in dissecting brain lesions – where the tiniest mistakes can wipe out aspects of the patient’s language skills or personality – to the bread-and-butter carpentry of shaving and fusing vertebral bone to release the pressure on injured spinal cords.

It was during his postgraduate training that the first signs of Nair’s weakness for drugs – cocaine in particular – began to surface. According to several colleagues who worked closely with him, Nair was widely known as a strange character who always appeared energised and enthusiastic. The prevailing belief was that he suffered a mental illness, probably bipolar disorder, but one that didn’t derail his work. For the most part, he was a competent doctor, successfully completing the training requirements. The prominent brain surgeon Charles Teo was a supporter and provided Nair with work references. Yet even Teo, who spoke out in support of Nair last April, also highlighted his personal shortcomings. As Teo told the Sydney Morning Herald: “Suresh didn’t have a balanced life, no social life. He was very awkward with girls and in my opinion it seemed like he couldn’t relate to women.”

Patrick Cregan, a general surgeon and head of quality assurance at Nepean Hospital, says that during the early stages of Nair’s decline seven or eight years ago several colleagues became concerned at his manner with patients, observing that he was uncharacteristically harsh and outspoken. He also began to arrive late to clinics, sometimes missing them altogether.

As a result of unusual behaviour and evidence of drug use, Nair was suspended in 2004, and again in 2008, after which he was forced to undergo regular urine tests and work under supervision. The second suspension related to his clinical practice and the complaint is still under investigation by the Health Care Complaints Commission. “There are significant holes in the concept of supervised practice,” says Cregan of the difficulty of working closely with a colleague in a small surgical department while also serving as an impartial overseer. Anthony Eyers, a colorectal surgeon and member of the Medical Council of New South Wales, the body entrusted to oversee doctors who have received complaints from the public or their colleagues, agrees: “It is a myth that you can supervise someone doing surgery.”

Six months before Nair’s arrest, an intense debate erupted among staff at Nepean Hospital about whether he should be allowed to return to work. A Medical Board–appointed psychiatrist provided a report acknowledging the concerns about Nair’s drug use and abnormal behaviour towards patients but stopping short of suspending him from practice. The hospital administrators remained anxious, so sought an independent psychiatric report, which Cregan says was “far more circumspect”. But, in spite of the concerns, Nair was ultimately allowed to return to work under supervision.

Cregan suspects Nair was cheating the drug tests, admitting that they are not as rigorous as tests for Olympic athletes. However, Peter Procopis, president of the NSW Medical Council, says that, while cheating is possible – strategies include bringing a prepared vial or even having a plastic penis filled with alternate urine to confuse those supervising – it is highly unlikely in this case.

Soon after Nair’s arrest came to public attention, several patients spoke out with complaints against him. Debbie Burns, a mother of two, was operated on by Nair only weeks before he was charged; she required a second operation to fix complications from the first and was told she was not likely to regain feeling in her left hand. Another patient, Helen Kerner, was already undertaking legal action against Sydney West Area Health Service for an alleged botched operation by Nair in 2006.

Some patients came out in public support of Nair, however, speaking favourably of his abilities. Helen Lonergan says she received a flurry of subpoenas from patients requesting to see their files after Nair’s case became public but that patient outcomes in the vast majority of his operations were very good.

Lonergan says the process has left many medical administrators asking: Who is ultimately responsible for an impaired doctor? She and other hospital administrators were perturbed by what they felt was poor communication between the supervisory groups in Nair’s case – the Medical Board, the supervisor and the Health Care Complaints Commission. These bodies all left Nepean Private Hospital in the dark about the true nature of Nair’s problems.

Procopis argues that cases like Nair’s are the exception rather than the rule, but says the Medical Board is ultimately responsible for doctors in breach of their duties. However, he adds that the hospital and employer also share some of the burden, despite often not being privy to all case details.

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Managing impaired doctors is a relatively new discipline. Two decades ago, the only way doctors could be held to account for questionable practice was if colleagues confronted them. A small, dedicated group from within the Australian Medical Association took on the burden of tapping on the shoulders of declining doctors – ageing physicians, for example, or surgeons with faltering physical prowess. But most members of the proud tribe of medicos were reluctant to take on this task.

Professor Merrilyn Walton, a former head of the Health Care Complaints Commission in NSW, cites a survey in which only 10% of doctors said they would definitely report a colleague for poor or inappropriate practice. “Doctors don’t always understand that it’s about protecting the public,” she says. “They also don’t see conflicts of interest very well.”

There has been a steady evolution in the way troubled doctors are dealt with over the past 20 years, with much of the action coming out of NSW. Repeated inquiries and royal commissions have resulted in that state leading the world in this area, according to Procopis. Regulations initiated in NSW have also been implemented nationally since registration of doctors came under a federal authority two years ago, replacing the old state-based system.

Professor Walton says of the particular focus in NSW on how to cope with impaired doctors: “It all began with Chelmsford.” The two-year royal commission into Chelmsford Private Hospital, which began in 1988, investigated deep sleep therapy and ‘psychosurgery’ (lobotomy) – treatments that resulted in the deaths of at least 24 patients at the hospital. The commission resulted in a swathe of recommendations, leading to the formation of the Health Care Complaints Commission, greater transparency of Medical Board decision-making, mandatory reporting guidelines, and a separation of disciplinary and impairment proceedings.

The recommendations of the Chelmsford Royal Commission were refined further after damning investigations emanating from the 2004 Inquiry into Campbelltown and Camden Hospitals in Western Sydney, where nurses had spoken out against a culture of bullying and cover-ups. Then, several years later, came the Garling Report into the public hospital system, precipitated by a waiting patient miscarrying a baby in the public toilets of the Royal North Shore Hospital emergency department. A key finding was that the super-specialisation of today’s doctors often results in no one taking full responsibility for a patient’s health; rather, doctors tend to limit themselves to offending organs, limbs or a specific bodily system.

These outside pressures forced doctors to confront their profession’s duty to the public. Yet the focus remains on maintaining a doctor in practice where possible, and delaying disciplinary measures. “It costs taxpayers over a million dollars to produce high-quality specialists, especially surgeons,” says Procopis. “It makes sense that every effort should be made, where possible, to keep them in practice.” But Walton suggests that the emphasis on the treatment and rehabilitation of doctors is excessive: “People fall through the cracks because their colleagues bend over backwards to help them rather than shift them to the disciplinary stage.”

I experienced such a tension as a psychiatric registrar after referring a good friend to a senior colleague, who ultimately behaved in sexually inappropriate ways towards her. I grappled with how to deal with the situation from my position as a considerably more junior doctor. I knew the psychiatrist would know that it was me if I reported him. So I said nothing, and have regretted my decision ever since. Similar tensions arose from the infamous case at Bundaberg Base Hospital, where the Queensland Public Hospitals Commission of Inquiry found that those best placed to witness Dr Jayant Patel’s transgressions were staff much lower down the hospital hierarchy – nurses, students and hospital orderlies.

Anthony Eyers describes Nair as “an example of someone who escaped the system”. One surgical colleague who operated on several of Nair’s patients after suspected complications tells me he believes there would have been “much more to come”, citing potential complaints and litigation from patients with poor outcomes, had Nair continued operating. A neurosurgical colleague and former supervisor of Nair’s, who last year was asked by the government to investigate the surgeon’s clinical practice, echoes this sentiment. Though he has signed a confidentiality agreement he hints that “there is much more to say about this case.”